"Warfarin (Coumadin) Maintenance Dosing Flow Sheet - Family Medicine Centre" - Canada

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Download "Warfarin (Coumadin) Maintenance Dosing Flow Sheet - Family Medicine Centre" - Canada

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Family Medicine Centre
Place patient label here
The Ottawa Hospital – Civic Campus
DRAFT
Sept 8, 2006
®
Warfarin (Coumadin
) maintenance dosing flow sheet
Date warfarin started:
Duration of treatment:
Phone #1:
Phone #2:
OK to leave message?
Yes
No
Comments
Indication:
Atrial fibrillation
Mechanical valve
Other:
Target range:
2.0-3.0
2.5-3.5
Other:
Tablet strength(s) available
Date of
When to
Clinician signature & date
Patient notified
INR
INR
Warfarin dose
recheck INR
(MD/RN)
(initials, date, time)
(dd/mm/yy)
Family Medicine Centre
Place patient label here
The Ottawa Hospital – Civic Campus
DRAFT
Sept 8, 2006
®
Warfarin (Coumadin
) maintenance dosing flow sheet
Date warfarin started:
Duration of treatment:
Phone #1:
Phone #2:
OK to leave message?
Yes
No
Comments
Indication:
Atrial fibrillation
Mechanical valve
Other:
Target range:
2.0-3.0
2.5-3.5
Other:
Tablet strength(s) available
Date of
When to
Clinician signature & date
Patient notified
INR
INR
Warfarin dose
recheck INR
(MD/RN)
(initials, date, time)
(dd/mm/yy)
Notes on warfarin maintenance dosing algorithm
®
For additional and detailed information, refer to the sheet “Warfarin (Coumadin
)
maintenance dosing algorithm”, kept at the front of the binder.
INR up to 4.9: Managed by nurse
Goal:
Goal:
Note: Adjust warfarin only if a change in INR is deemed to be permanent.
2.0-3.0
2.5-3.5
• Consider reloading with 1 extra dose of warfarin.
< 2.0
< 2.5
• Increase warfarin by 5-15%.
• No change.
2.0-3.0
2.5-3.5
• Decrease warfarin by 5-15%.
3.1-3.5
3.6-4.0
• Hold 1 dose of warfarin.
3.6-4.0
4.1-4.5
• Decrease warfarin by 5-15%.
• Hold warfarin until INR in therapeutic range.
• Decrease warfarin by 5-15%.
4.1-4.9
4.6-4.9
• Consider low dose Vitamin K if high risk of bleeding (consult physician).
Use of the algorithm
• This algorithm is to be used by nurses and physicians in the Family Medicine Unit.
• Under the terms of the medical directive, the recommendations for managing INRs up to 4.9 may be followed by
the nursing staff without consulting a physician.
• The nursing component can be instituted once a patient newly started on warfarin has had 2 consecutive INRs in
the therapeutic range.
• The patient’s physician must be notified immediately and, in most cases, take over direct management of warfarin
dosing under the following circumstances:
- the INR is 5.0 or greater,
- an unexpected significant change of the INR result over a patient’s established level, even if it does not exceed 4.9, or
- any amount of unexpected or prolonged bleeding,
- any time the status of the patient changes in any way that does or may affect the anticoagulation status.
• The patient’s physician should place the patient back on the nurses’ algorithm once he/she has decided the
patient’s status has stabilized. This must be communicated directly with the nursing staff.
• Note on flexibility: The dosing and INR recommendations outlined in this algorithm should be followed in most
cases. Occasionally, a nurse may exercise judgment for minor deviations outside the defined INR limits. Some of
the possibilities are described below.
Dose adjustments
• Do not change the dose if a single INR result is slightly out of range (i.e. it is neither very high nor very low).
• Change doses only if there is a trend toward or established lower or higher INR results.
• Choose a lower or higher range depending on the degree of decrease or elevation, historic response of
adjustments by patient, the patient’s risk profile, and convenience of dosing (availability of tablets).
• Make adjustments based on total weekly dose. But use daily dosing (versus Mon-Fri and Sat-Sun dosing)
whenever possible. Adjustments can be made slightly below or above range (e.g. 5-25%) to accommodate dosing
convenience (i.e. rounding of doses to nearest .25 or .5).
• The decision to hold one or multiple doses should be based on the degree of INR elevation, the risk or presence of
bleeding, and an assessment of the cause and duration of elevated INR (e.g. if INR will continue to increase based
on change in disease or concurrent medications).
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